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Starting a 3-D lab in a community radiology practice

Introduction

Over the course of the last 10 years, CT studies have become much more complex and the modality itself has become much more robust. A large part of this growth emanates from the new imaging opportunities that allow for volumetric data acquisition orded by the multislice-CT scanners, combined with the explosion in software development. This has opened the door to many new clinical opportunities, such as CT angiography, a full range of cardiac applications, volumetric analyses, virtual colonography, computer assisted diagnosis (CAD), fusion imaging, and more. How to handle the post-processing of these studies became the next issue to address. Some radiologists subscribed to the school of thought that the radiologist should be interacting with the volumetric data from the beginning to the end of the process, and that there was no need for an intermediary post-processing step. However, others have thought differently. Post-processing by skilled operators (e.g. specialized technologists, radiology residents) was a necessary intermediary step that brought efficiency and other benefits.

It was then that the concept of centralized post-processing emerged. Originally reserved for the academic centers that possessed multifaceted ancillary resources (e.g. radiology residents and fellows, computer scientists and engineers, specialized radiology technologists, radiology technology schools), the term "3-D lab" caught on and reflected both the clinical and research value of such a centralized post-processing facility. It was part assembly line and part think-tank.

Since the early 3-D labs, however, a number of technological improvements have been made. Coinciding with the movement of some of the high tech state-of-the-art clinical applications out of the academic centers and into the general community, these technological improvements are preparing the ground for a roll-out of these efficiency centers into the general community. In order to launch such an endeavor in a community practice, however, the members of that practice must have insight, organizational management skills, and good strategic planning skills. The goal of this presentation is to outline the benefits of a centralized 3-D post-processing lab, and to briefly introduce some of the factors and variables that must be addressed in order to successfully launch such an endeavor.

Of course, the answers to all of these questions are predicated on the understanding of the true value of a centralized post-processing 3-D lab. Some of those benefits are obvious. Others require insight. Here are the major points:

EFFICIENCY: By having specialized technologists do the major post-processing, the work gets split between radiologist and technologist. This split is typically not a 50-50 split. Indeed, in the ideal situation it is much more heavily weighted toward the technologist. In our practice, once we introduced our 3-D lab operations, we observed a decrease in the amount of time required for a neuroradiologist to review and interpret a neurovascular CTA of the aortic arch, neck, and head from an average of 35-40 minutes per patient to under 10 minutes. But efficiency is not achieved by having specialized technologists handle the post-processing. There are many factors and many workflow processes that need to be instituted in order to get these results. These will be alluded to later on.

IMPROVED CLINICAL SERVICE: the rolling out of new diagnostic imaging tests (e.g. CTA, virtual colonography, cardiac imaging) is right and good, when done correctly. It is our mission, our pledge, our oath.

QUALITY: in each practice there are radiologists with variable skills and funds of knowledge. When there are variable computer skills, in particular, this opens the door for variable accuracy in the interpretations. The goal, of course, in every practice is consistent high quality, accurate interpretations. By having a centralized post-processing service, a practice is well on its way to standardizing the end-product and eliminating the other variables that could otherwise bring down what could have been a valuable clinical service. In essence, the 3-D lab levels the playing field among the radiologists and can be a critical instrument for quality assurance.

PROFITABLE: When done correctly, the 3-D lab can be a profit center. Everyone wins. The patients receive better care; the clinicians have better information on which to base clinical decision-making; the hospital rides the wave of introducing more cutting-edge initiatives; and the radiologists are compensated for their insight and expertise.

MORALE: the technologists chosen to participate in endeavors such as these typically are excited to join in as they sense the cutting edge nature of these new horizons. This enthusiasm can spread in many directions.

The ingredients

A 3-D lab is a multifaceted initiative that requires insight and ingenuity to launch. A comprehensive analysis is beyond the scope of this discussion, but certain salient points are certainly worthy of comment and can serve as an orientation.

Workstation Technology and connectivity - powerful, user-friendly hardware and software is obviously one of the cornerstones of a successful 3D processing center. Choosing the right technology, optimally suited for the staff, is critical. Connectivity to PACS and interconnectivity between sites and equipment is important and must be customized, to some degree, to the site.

Staffing - this relates to both the technologists and the radiologists who will be involved in this initiative. The technologists must be smart and motivated ("super-techs"), willing to learn anatomy and pathology in addition to post-processing skills. Each new clinical application will need a physician champion - one of the radiologists who makes it his/her own. The physician champion will work closely with the technologists and the technology companies in that particular application, and is ultimately responsible for establishing the various protocols and workflow processes for that application.

Processes and protocols - this is perhaps the most challenging and yet the most stimulating dimension of the entire enterprise. This is where organizational skills and insight come in to play. Here are some examples:

1. Establishing processing and filming protocols - one way to achieve efficiency is to have consistency. All studies of a certain clinical application should, in the end, have a prescribed set of images (a processing protocol), arranged in a predefined and consistent order. So, for example studies in our practice are all imaged in the same way and in the same sequence. This allows for a rhythm of review and dictation, ultimately leading to greater efficiency and consistency.

2. Workflow - for each clinical application, efficiency and consistency are dependent upon a keen sense on the part of the technologist and the radiologist of what each one is supposed to do in the process. While a certain amount of overlap and duplication of effort may be present, and indeed is at times wise, too much overlap and redundancy leads to failure. This is like a relay race. One runner must hand off the baton to the next runner. They overlap a bit during the handoff, but each one knows where he/she is supposed to be and where the other one is supposed to be as well. Each one knows where to start and where to end. They're in sync.

3. Communication - it is not enough for the technologist to do some or most of the post-processing before the study reaches the mouse of the radiologist, there must be a line of communication between the two so that the radiologist can gain the most benefit from the technologist's efforts. This is not very different from the relationship that exists between a radiologist and an ultrasound technologist where the former would like to know the overall impression of the astute technologist, and where that opinion may be assigned much significance by the radiologist. So, too, the astute 3-D technologist can register measurements and opinions, and there must be a way to convey them to the radiologist.

4. Prioritization - some formal or informal prioritization process must be set into action to insure that studies that must be reviewed in a more urgent manner are processed out before other lower priority studies.

Technologist training - as mentioned, this refers not only to workstation training, but to instruction in anatomy and pathology that, in general, is in greater depth than they have encountered before. Comprehensive training requires an investment of time and energy, but is well worth it. Experienced technologists can then also train new technologists. In a successful 3D lab, the technologists often ultimately understand the strengths and weaknesses of the workstation technology much better than the radiologists, and can serve as point persons or consultants to the workstation manufacturers.

Sound business model - many business models exist. Increased numbers of procedures for those practices that collect the global or technical fees is one factor. For those practices contracted with institutions, where the institutions collect the technical fees, one can always consider various reimbursement/compensation programs where the costs of the 3-D are shared and/or where the health care system pays the practice a 3-D processing fee per study or patient.

Strategic and Tactical planning - like any other complex, multifaceted initiative, successful implementation of a 3-D lab requires good planning. A phased roll-out plan is one such example. Many new and exciting clinical applications can be launched through a 3-D lab. Patience and timing are virtues. For example, begin with one or two new clinical applications. Identify your radiologist champions, have your technologists educated and trained, set up your workflow processes and monitor them, market the new services appropriately, etc. Several months later, when those new applications are on relative autopilot, then launch additional, new clinical applications.

IT support - a must. This does not have to be a full FTE, but it does need to be someone who is knowledgeable and readily available at the drop of a hat to troubleshoot. This is complex. The connectivity issues themselves can be a challenge to comprehend and maintain.

Quality Assurance - any new initiative of this complexity is worthy of undergoing on-going review and monitoring. Performance improvement parameters need to be defined and mechanisms of review and assessment established.

About the author

Dr. Jay Cinnamon is a Board Certified Radiologist with an interest in Neuroradiology, advanced CT, and 3D-imaging. He received his MD degree from Albert Einstein School of Medicine in 1985 and is fellowship trained in Neuroradiology. His areas of particular expertise are advanced CT scan applications, stroke, brain tumor evaluation, pediatric neuroradiology, and spine disease. He is an active member of the American College of Radiology, Radiological Society of North America, American Society of Neuroradiology, and American Society of Pediatric Neuroradiology. Before joining Quantum Radiology Northwest, Dr. Cinnamon was the Director of Neuroradiology at Emory University School of Medicine. He has given over 140 lectures at national meetings over the last several years and is credited as the author of the term "multislice", the term used internationally in regard to the latest generation of CT scan technology. Dr. Cinnamon is one of the few radiologists from across the country who has been selected to serve as an examiner for the radiology boards examination, and continues to function as a manuscript reviewer for national radiology journals.